l INTERACTIONS → Appendix 1: glycopyrronium . neostigmine
l DIRECTIONS FOR ADMINISTRATION For intravenous
injection, give over 10–30 seconds.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Neostigmine with glycopyrronium bromide (Non-proprietary)
Glycopyrronium bromide 500 microgram per 1 ml, Neostigmine
metilsulfate 2.5 mg per 1 ml Neostigmine 2.5mg/1ml /
Glycopyrronium bromide 500micrograms/1ml solution for injection
ampoules | 10 ampoule P £11.50
Routine reversal of neuromuscular blockade induced by
▶ Adult: Initially 2–4 mg/kg, then 4 mg/kg if required,
administered if recurrence of neuromuscular blockade
occurs; consult product literature for further details
Immediate reversal of neuromuscular blockade induced
▶ Adult: 16 mg/kg (consult product literature)
Should only be administered by, or under the direct
supervision of, personnel experienced in its use.
l CAUTIONS Cardiovascular disease (recovery may be
delayed). elderly (recovery may be delayed). pre-existing
coagulation disorders .recurrence of neuromuscular
blockade— monitor respiratory function until fully
24 hours before re-administering vecuronium
l INTERACTIONS → Appendix 1: sugammadex
complications . skin reactions .taste altered . vomiting
▶ Frequency not known Bronchospasm
l PREGNANCY Use with caution—no information available.
l RENAL IMPAIRMENT Avoid if eGFR less than
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium, has advised (February
2013) that sugammadex (Bridion ®) is accepted for
restricted use within NHS Scotland for the routine reversal
of neuromuscular blockade in high-risk patients only, or
where prompt reversal of neuromuscular block is required.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
ELECTROLYTES: May contain Sodium
▶ Bridion (Merck Sharp & Dohme Ltd)
Sugammadex (as Sugammadex sodium) 100 mg per 1 ml Bridion
500mg/5ml solution for injection vials | 10 vial P £1,491.00
Bridion 200mg/2ml solution for injection vials | 10 vial P £596.40
Since non-steroidal anti-inflammatory drugs (NSAIDs) do
not depress respiration, do not impair gastro-intestinal
motility, and do not cause dependence, they may be useful
alternatives or adjuncts to opioids for the relief of
postoperative pain. NSAIDs may be inadequate for the relief
of severe pain. Diclofenac sodium p. 1135, diclofenac
potassium p. 1135, flurbiprofen p. 1140, ibuprofen p. 1141,
ketoprofen p. 1144, paracetamol p. 444, parecoxib p. 1342,
and ketorolac trometamol p. 1342 are licensed for
postoperative use. Diclofenac and paracetamol can be given
by injection as well as by mouth. Diclofenac sodium can be
given by intravenous infusion for the treatment or
prevention of postoperative pain. Intramuscular injections
of diclofenac sodium and ketoprofen are rarely used; they
are given deep into the gluteal muscle to minimise pain and
tissue damage. Ketorolac trometamol is less irritant on
intramuscular injection but pain has been reported; it can
also be given by intravenous injection.
Suppositories of diclofenac sodium and ketoprofen may be
effective alternatives to the parenteral use of these drugs.
Opioid analgesics are now rarely used as premedicants; they
those patients who require control of existing pain. See
general notes on opioid analgesics and their use in
See the management of opioid-induced respiratory
depression in Pre-medication and peri-operative drugs
Opioid analgesics given in small doses before or with
induction reduce the dose requirement of some drugs used
Alfentanil p. 1343, fentanyl p. 458, and remifentanil
p. 1344 are particularly useful because they act within
1–2 minutes and have short durations of action. The initial
doses of alfentanil or fentanyl are followed either by
successive intravenous injections or by an intravenous
infusion; prolonged infusions increase the duration of effect.
Repeated intra-operative doses of alfentanil or fentanyl
should be given with care since the resulting respiratory
depression can persist postoperatively and occasionally it
may become apparent for the first time postoperatively when
monitoring of the patient might be less intensive. Alfentanil,
fentanyl, and remifentanil can cause muscle rigidity,
particularly of the chest wall or jaw; this can be managed by
the use of neuromuscular blocking drugs.
In contrast to other opioids which are metabolised in the
liver, remifentanil undergoes rapid metabolism by
nonspecific blood and tissue esterases; its short duration of
action allows prolonged administration at high dosage,
without accumulation, and with little risk of residual
postoperative respiratory depression. Remifentanil should
not be given by intravenous injection intraoperatively, but it
is well suited to continuous infusion; a supplementary
analgesic is given before stopping the infusion of
1340 Anaesthesia adjuvants BNF 78
ANAESTHETICS, GENERAL › NMDA RECEPTOR
l DRUG ACTION Esketamine is an isomer of ketamine that
blocks N-methyl-D-aspartate (NMDA) receptors and
interrupts the association pathways of the brain, resulting
in dissociative anaesthesia and analgesia.
Induction and maintenance of anaesthesia (specialist use
▶ BY SLOW INTRAVENOUS INJECTION
▶ Adult: 0.5–1 mg/kg, then maintenance 0.25–0.5 mg/kg
every 10–15 minutes, adjusted according to response
▶ Adult: 2–4 mg/kg, then maintenance 1–2 mg/kg every
10–15 minutes, adjusted according to response
▶ BY CONTINUOUS INTRAVENOUS INFUSION
▶ Adult: 0.5–3 mg/kg/hour, adjusted according to
Analgesic supplementation of regional and local
anaesthesia (specialist use only)
▶ BY CONTINUOUS INTRAVENOUS INFUSION
▶ Adult: 0.125–0.25 mg/kg/hour, adjusted according to
Analgesia in emergency medicine (specialist use only)
▶ Adult: 0.25–0.5 mg/kg, adjusted according to response
▶ BY SLOW INTRAVENOUS INJECTION
▶ Adult: 0.125–0.25 mg/kg, adjusted according to
Esketamine should only be administered by, or under the
direct supervision of, personnel experienced in its use,
with adequate training in anaesthesia and airway
management, and when resuscitation equipment is
anaesthetic agent). patients in whom hypertension or
raised intracranial pressure forms a serious risk . preeclampsia
cerebrospinal fluid pressure . patients with multiple
l INTERACTIONS → Appendix 1: esketamine
disorders .respiratory secretion increased . sleep disorders . vision disorders . vomiting
▶ Uncommon Muscle tone increased . nystagmus . skin
▶ Rare or very rare Hypotension
l PREGNANCY Manufacturer advises use only if potential
benefit outweighs risk—may depress neonatal respiration
l BREAST FEEDING Manufacturer advises present in milk—
not thought to be harmful at therapeutic doses.
l HEPATIC IMPAIRMENT Manufacturer advises caution (risk
Dose adjustments Manufacturer advises consider dose
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
solution can be diluted with Glucose 5% or Sodium
Driving and skilled tasks Patients given sedatives and
analgesics during minor outpatient procedures should be
very carefully warned about the risk of driving or
undertaking skilled tasks afterwards. For a short general
anaesthetic the risk extends to at least 24 hours after
administration. Responsible persons should be available to
take patients home. The dangers of taking alcohol should
For information on 2015 legislation regarding driving
whilst taking certain controlled drugs, including ketamine
which has similar pharmacokinetic properties to
esketamine, see Drugs and driving under Guidance on
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Esketamine (as Esketamine hydrochloride) 5 mg per
1 ml Vesierra 25mg/5ml solution for injection ampoules |
10 ampoule P £18.98 (Hospital only)b
Esketamine (as Esketamine hydrochloride) 25 mg per
1 ml Vesierra 50mg/2ml solution for injection ampoules | 10 ampoule P £26.31 (Hospital only)b
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, bupivacaine hydrochloride p. 1349, fentanyl
During labour (once epidural block established)
▶ BY CONTINUOUS LUMBAR EPIDURAL INFUSION
▶ Adult: 10–18.75 mg/hour, dose of bupivacaine to be
administered, maximum 400 mg bupivacaine in
24 hours and 16–30 micrograms/hour, dose of fentanyl
to be administered, maximum 720 micrograms fentanyl
Postoperative pain (once epidural block established)
▶ BY CONTINUOUS EPIDURAL INFUSION
▶ Adult: 4–18.75 mg/hour, dose of bupivacaine to be
administered, maximum 400 mg bupivacaine in
24 hours and 8–30 micrograms/hour, dose of fentanyl
to be administered, maximum 720 micrograms fentanyl
in 24 hours, to be administered by thoracic, upper
abdominal or lower abdominal epidural infusion
l INTERACTIONS → Appendix 1: anaesthetics, local . opioids
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: infusion, solution
Fentanyl 2 microgram per 1 ml, Bupivacaine hydrochloride 1 mg
per 1 ml Bufyl 1mg/ml and 2micrograms/ml 250ml infusion bags | 20 bag P £170.00 (Hospital only)b
Bufyl 1mg/ml and 2micrograms/ml 500ml infusion bags | 10 bag P £92.00 (Hospital only)b
Fentanyl (as Fentanyl citrate) 2 microgram per 1 ml, Bupivacaine
hydrochloride 1.25 mg per 1 ml Bufyl 1.25mg/ml and
BNF 78 Peri-operative analgesia 1341
2micrograms/ml 250ml infusion bags | 20 bag P £181.00
Bufyl 1.25mg/ml and 2micrograms/ml 500ml infusion bags |
10 bag P £92.00 (Hospital only)b
ANALGESICS › NON-STEROIDAL ANTIINFLAMMATORY DRUGS
Ketorolac trometamol 13-Aug-2018
Short-term management of moderate to severe acute
▶ BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
▶ Adult (body-weight up to 50 kg): Initially 10 mg, then
10–30 mg every 4–6 hours as required for maximum
duration of treatment 2 days, frequency may be
increased to up to every 2 hours during initial
postoperative period; maximum 60 mg per day
▶ Adult (body-weight 50 kg and above): Initially 10 mg,
then 10–30 mg every 4–6 hours as required for
maximum duration of treatment 2 days, frequency may
be increased to up to every 2 hours during initial
postoperative period; maximum 90 mg per day
▶ Elderly: Initially 10 mg, then 10–30 mg every 4–6 hours
as required for maximum duration of treatment 2 days,
frequency may be increased to up to every 2 hours
during initial postoperative period; maximum 60 mg
ulceration . coagulation disorders . complete or partial
syndrome of nasal polyps . confirmed or suspected
cerebrovascular bleeding . dehydration . following
operations with high risk of haemorrhage or incomplete
l CAUTIONS Allergic disorders . cardiac impairment (NSAIDs
disease . peripheral arterial disease .risk factors for
cardiovascular events . ulcerative colitis (may be
exacerbated). uncontrolled hypertension
l INTERACTIONS → Appendix 1: NSAIDs
pain . fluid retention . flushing . gastrointestinal
discomfort. gastrointestinal disorders . haemolytic
anaemia . haemorrhage . hallucination . headache . hearing
aseptic (patients with connective-tissue disorders such as
systemic lupus erythematosus may be especially
aggregation inhibition . psychotic disorder. pulmonary
reactions . sleep disorders . stroke .taste altered .thinking
SIDE-EFFECTS, FURTHER INFORMATION For information
about cardiovascular and gastrointestinal side-effects, and
a possible exacerbation of symptoms in asthma, see Nonsteroidal anti-inflammatory drugs. p. 1130
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with a history of hypersensitivity to aspirin or any
other NSAID—which includes those in whom attacks of
asthma, angioedema, urticaria or rhinitis have been
precipitated by aspirin or any other NSAID.
l CONCEPTION AND CONTRACEPTION Caution—long-term
use of some NSAIDs is associated with reduced female
fertility, which is reversible on stopping treatment.
l PREGNANCY Avoid unless the potential benefit outweighs
the risk. Avoid during the third trimester (risk of closure of
fetal ductus arteriosus in utero and possibly persistent
pulmonary hypertension of the newborn); onset of labour
may be delayed and duration may be increased.
l BREAST FEEDING Amount too small to be harmful.
l HEPATIC IMPAIRMENT Manufacturer advises caution—may
increase risk of renal impairment; avoid in hepatic failure.
l RENAL IMPAIRMENT Avoid if possible or use with caution.
Avoid if serum creatinine greater than 160 micromol/litre.
Dose adjustments The lowest effective dose should be used
for the shortest possible duration. Max. 60 mg daily by
intramuscular injection or intravenous injection.
Monitoring In renal impairment monitor renal function;
sodium and water retention may occur and renal function
may deteriorate, possibly leading to renal failure.
l DIRECTIONS FOR ADMINISTRATION For intravenous
injection, give over at least 15 seconds.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Ketorolac trometamol (Non-proprietary)
Ketorolac trometamol 30 mg per 1 ml Ketorolac 30mg/1ml solution
for injection ampoules | 5 ampoule P £15.60–£20.00 DT = £5.36
▶ Toradol (Atnahs Pharma UK Ltd)
Ketorolac trometamol 30 mg per 1 ml Toradol 30mg/1ml solution
for injection ampoules | 5 ampoule P £5.36 DT = £5.36 (Hospital
l DRUG ACTION Parecoxib is a selective inhibitor of cyclooxygenase-2.
Short-term management of acute postoperative pain
▶ BY DEEP INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
▶ Adult: Initially 40 mg, then 20–40 mg every 6–12 hours
as required for up to 3 days; maximum 80 mg per day
▶ Elderly (body-weight up to 50 kg): Initially 20 mg;
disease . inflammatory bowel disease . ischaemic heart
disease . mild to severe heart failure . peripheral arterial
l CAUTIONS Allergic disorders . cardiac impairment (NSAIDs
graft surgery . history of cardiac failure . hypertension. left
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